C947 Task 1 Education Program Design Example

Nursing Education Capstone: A Simulation-Based Emergency Birth Readiness Program for Nurses in a Rural Emergency Department After the Local Obstetric Unit Closed

Student Name

Leavitt School of Health, Western Governors University

C947: Nursing Education Capstone, Task 1

Course Instructor

Month Day, Year

Nursing Education Capstone: A Simulation-Based Emergency Birth Readiness Program for Nurses in a Rural Emergency Department After the Local Obstetric Unit Closed

The Educational Need

Across rural America, hospitals have been closing obstetric units, and births move to places that were never designed for them. Between 2004 and 2014, 179 rural counties lost hospital-based obstetric services, and in the year after the loss, remote rural counties recorded more out-of-hospital births, more deliveries at hospitals lacking obstetric units and more preterm births (Kozhimannil et al., 2018). The setting for this program is a composite 25-bed rural hospital whose labor and delivery unit closed two years ago. The nearest obstetric unit is 52 miles away. Since the closure, the hospital's emergency department (ED) has recorded 11 births in the department or in the parking area, two of them preterm, and 38 women in active labor who were stabilized and transferred.

A needs assessment was conducted with the ED's 19 registered nurses using a short confidence survey, a review of the 11 birth records and interviews with the ED medical director and the transfer coordinator. On a five-point scale, nurses rated their confidence at 1.9 for managing a shoulder dystocia, 2.1 for managing postpartum hemorrhage and 2.4 for initial newborn resuscitation. Only 6 of 19 held current neonatal resuscitation certification. Record review found that in 4 of the 11 births, newborn temperature was not documented in the first hour, and in 3, oxytocin was given later than 15 minutes after delivery of the baby. These gaps are knowledge and skill gaps in rare, high-stakes events, which points to simulation rather than lecture.

Learners and Program Goal

The learners are the ED's registered nurses, most of whom have not worked in obstetrics, and the program is open to the two nurse practitioners who staff the ED at night. The goal is that every ED nurse can recognize imminent birth, prepare the room and equipment, assist a normal birth, respond to the two most common maternal emergencies and perform initial newborn care and resuscitation until transfer.

Learning Objectives

After completing the program, the nurse will be able to: (1) identify signs of imminent birth and decide between transfer and delivery in the department using the hospital's criteria; (2) set up the precipitous delivery cart and warming equipment within five minutes; (3) assist with a normal vaginal birth, including delayed cord clamping when appropriate; (4) perform the first steps of neonatal resuscitation according to current Neonatal Resuscitation Program guidance (American Academy of Pediatrics & American Heart Association, 2021); (5) recognize postpartum hemorrhage early and carry out the hospital's hemorrhage protocol, including quantitative blood loss measurement and timely uterotonic administration; and (6) communicate clearly during an obstetric emergency using closed-loop communication.

Content Outline

The content follows the order in which an ED nurse meets the problem. It begins with recognition: the signs that birth is imminent, how to check without a full obstetric examination and when transfer is safer than delivery. It moves to preparation: calling for help, opening the precipitous delivery cart, warming the room and the radiant warmer and assigning roles. It then covers the birth itself and the immediate care of the newborn, including drying, warming, assessing breathing and heart rate and beginning ventilation when needed. The final block addresses the mother after birth: fundal assessment, measuring blood loss, giving a uterotonic promptly and recognizing the signs that hemorrhage is outpacing the protocol. Each block ends with the documentation that record review found missing, so the teaching answers the local gaps directly.

Program Design

The program has three parts and takes about seven hours per nurse over two months.

Simulation Design

Each scenario is designed according to the Healthcare Simulation Standards of Best Practice for simulation design, which call for a needs assessment, measurable objectives, a scenario that fits the objectives, appropriate fidelity, a prebriefing, a structured debriefing and evaluation (Watts et al., 2021). Scenarios will be run in the ED's own resuscitation bay, using the department's equipment, so nurses rehearse where the event will actually happen. Each scenario runs for 15 to 20 minutes followed by a 30-minute debriefing led by a trained facilitator, since debriefing is where most of the learning in simulation occurs. The hemorrhage scenario includes a planned delay in the transfer helicopter, which tests the team's ability to continue management rather than wait.

Implementation

The ED nurse manager has approved paid time for all three parts. Skills stations and simulation days will be scheduled on six dates over two months, with no more than four nurses per simulation day so that each nurse takes an active role in at least two scenarios. The nearest obstetric hospital has agreed to lend a labor nurse educator as co-facilitator for two simulation days. Costs are modest: a low-fidelity birthing simulator and newborn manikin borrowed from the regional simulation center, supplies from the ED's stock, and paid education hours for 19 nurses.

Evaluation

The program will be evaluated at four levels (Kirkpatrick & Kirkpatrick, 2016). Reaction: a post-program survey on relevance and realism. Learning: the confidence survey repeated after the program, a 15-item knowledge check before and after the online module, and a skills checklist completed at each station. Behavior: in-situ mock births run unannounced in the ED twice a year, scored with the same checklist, and review of every real birth record for newborn temperature documentation and uterotonic timing. Results: over the following year, the proportion of ED births with complete newborn temperature documentation and uterotonic given within 15 minutes, compared with the 11 births in the needs assessment. Because births remain rare, the results level will be reported as case counts rather than rates.

Sustainability

Skills for rare events fade, so the program becomes an annual requirement, with new ED nurses completing it within their first six months. Two ED nurses who complete the program will attend facilitator training so the department does not depend on outside educators, and the unannounced mock births will continue as a standing part of the ED's education calendar.

References

American Academy of Pediatrics & American Heart Association. (2021). Textbook of neonatal resuscitation (8th ed.). American Academy of Pediatrics.

Kirkpatrick, J. D., & Kirkpatrick, W. K. (2016). Kirkpatrick's four levels of training evaluation. ATD Press.

Kozhimannil, K. B., Hung, P., Henning-Smith, C., Casey, M. M., & Prasad, S. (2018). Association between loss of hospital-based obstetric services and birth outcomes in rural counties in the United States. JAMA, 319(12), 1239-1247. https://doi.org/10.1001/jama.2018.1830

Watts, P. I., McDermott, D. S., Alinier, G., Charnetski, M., Ludlow, J., Horsley, E., Meakim, C., & Nawathe, P. A. (2021). Healthcare simulation standards of best practice: Simulation design. Clinical Simulation in Nursing, 58, 14-21. https://doi.org/10.1016/j.ecns.2021.08.009